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Care for the critical care provider, too?
Tartaglia A, Dodd-McCue D, Kuthy S, Myer K, Faulkner K.
Program in Patient Counseling, Virginia Commonwealth University, Richmond, Va., USA.
PMID: 14619360 [PubMed - indexed for MEDLINE]
Comment in:
Legal aspects of withdrawal of therapy.
Young RJ, King A.
Intensive Care Unit, Royal Adelaide Hospital, North Terrace, Adelaide, S.A. 5000.
The ability of intensive care to replace or support vital organ function has resulted in some patients surviving for long periods of time without improvement or a terminal event. In patients with no realistic chance of survival, decisions to withdraw or withhold life-sustaining therapies are commonly made. Withdrawal of life support at the patient's request is lawful at common law and, in some states of Australia, by legal statute. In the intensive care setting though, it is more common for therapy to be withdrawn because the therapy is of no perceived benefit or not in the patient's best interests. However, in Australia there is little case law and very little legislation to direct the decision of whether to withdraw life-sustaining therapy on the grounds of futility or the patient's best interests. The legislation that does exist in Australia, as well as law from other jurisdictions, largely places responsibility for the decision to withdraw therapy on the doctor in charge of the patient's care. However much weight is frequently placed on the wishes of the family. Disagreements between family and clinicians over decisions to withdraw therapy are unusual and generally resolve over time. However if disagreement persists, it may be advisable to apply to the courts for a declaratory judgement, given the tenuous legal basis of withdrawal of life-sustaining therapy in Australia and the uncertainty over the courts' view of the role of the patient's family in the decision-making process.
Publication Types:
PMID: 14601271 [PubMed - indexed for MEDLINE]
Organizational changes in a single intensive care unit affect benchmarking.
van Zanten AR, Polderman KH.
Publication Types:
PMID: 15096357 [PubMed - in process]
Projected benefits of active surveillance for vancomycin-resistant enterococci in intensive care units.
Perencevich EN, Fisman DN, Lipsitch M, Harris AD, Morris JG Jr, Smith DL.
Veterans' Affairs Maryland Healthcare System, Baltimore, Maryland, USA. eperence@epi.umaryland.edu
Hospitals use many strategies to control nosocomial transmission of vancomycin-resistant enterococci (VRE). Strategies include "passive surveillance," with isolation of patients with known previous or current VRE colonization or infection, and "active surveillance," which uses admission cultures, with subsequent isolation of patients who are found to be colonized with VRE. We created a mathematical model of VRE transmission in an intensive care unit (ICU) using data from an existing active surveillance program; we used the model to generate the estimated benefits associated with active surveillance. Simulations predicted that active surveillance in a 10-bed ICU would result in a 39% reduction in the annual incidence of VRE colonization when compared with no surveillance. Initial isolation of all patients, with withdrawal of isolation if the results of surveillance cultures are negative, was predicted to result in a 65% reduction. Passive surveillance was minimally effective. Using the best available data, active surveillance is projected to be effective for reducing VRE transmission in ICU settings.
PMID: 15095215 [PubMed - in process]
Comment on:
Atrial fibrillation in the surgical intensive care unit: Common but understudied.
Pinski SL.
Publication Types:
PMID: 15090986 [PubMed - indexed for MEDLINE]
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Reporting of medical errors: an intensive care unit experience.
Osmon S, Harris CB, Dunagan WC, Prentice D, Fraser VJ, Kollef MH.
Pulmonary and Critical Care Division, Washington University School of Medicine, St. Louis, MO, USA.
OBJECTIVE: To determine the occurrence and type of medical errors in an intensive care setting using a voluntary reporting method. DESIGN: Prospective, single-center, observational study. SETTING: The medical intensive care unit (19 beds) at an urban teaching hospital. PATIENTS: Adult patients requiring at least 48 hrs of intensive care. INTERVENTIONS: Prospective reporting of medical errors. MEASUREMENTS AND MAIN RESULTS: During a 6-month period, 232 medical events were reported involving 147 patients. A total of 2598 patient days were surveyed yielding 89.3 medical events reported per 1000 intensive care unit days. The source of the reports included nurses, who reported most of the medical events (59.1%), followed by physicians-in-training (27.2%) and intensive care unit attending physicians (2.6%). One hundred thirty (56.2%) medical events occurred within the intensive care unit and were judged to involve patient careproviders who were working directly in the intensive care unit area. One hundred and two (43.8%) medical events were commissions or omissions that occurred outside of the intensive care unit during patient transports or in the emergency department and hospital floors. Twenty-three (9.9%) medical events leading to a medical error resulted in the need for additional life-sustaining treatment, and seven (3.0%) medical errors may have contributed to patient deaths. CONCLUSION: Medical errors appear to be common among patients requiring intensive care. Medical events resulting in an error can result in the need for additional life-sustaining treatments and, in some circumstances, can contribute to patient death. Patient healthcare providers appear to be in a unique position to identify medical errors. Institutions should develop formalized methods for the reporting and analysis of medical errors to improve patient care.
PMID: 15090954 [PubMed - indexed for MEDLINE]
Comment in:
Incidence and risk factors of atrial fibrillation in a surgical intensive care unit.
Seguin P, Signouret T, Laviolle B, Branger B, Malledant Y.
Surgical Intensive Care Unit, Hopital Pontchaillou, Rennes, France.
OBJECTIVE: To evaluate the incidence and risks factors of atrial fibrillation (AF). DESIGN: Prospective, observational study. SETTING: A surgical intensive care unit of a university hospital. PATIENTS: All patients with new onset of AF admitted in the surgical intensive care unit during a 6-month period. INTERVENTIONS: None. MEASUREMENT AND MAIN RESULTS: Of the 460 patients included in the study, AF developed in 24 patients (5.3%). According to univariate analysis, age, preexisting cardiovascular disease, and previous treatment by calcium-channel blockers were significant predictors of AF. Patients with AF received significantly more fluids and catecholamines and experienced more sepsis, shock, and acute renal failure. Severity (Simplified Acute Physiologic Score II), intensive care unit workload (OMEGA), intensive care unit and hospital length of stay, and mortality were significantly increased in patients who developed AF. Multivariate analysis identified five independent predictors of AF: advanced age, blunt thoracic trauma, shock, pulmonary artery catheter, and previous treatment by calcium-channel blockers. CONCLUSIONS: In surgical intensive care unit patients, the incidence of AF is greater than in the general population but less than in the cardiac surgery unit. The onset of AF reflects the severity of the disease. Five independent risk factors of AF were identified in surgical intensive care unit patients. The withdrawal of a calcium-channel inhibitor was also an independent risk factor of AF, and the weaning of this treatment must be carefully evaluated. Blunt thoracic trauma increases the chances of developing AF, as does the presence of shock, especially septic shock.
PMID: 15090953 [PubMed - indexed for MEDLINE]
Comment in:
Combined external and internal hospital disaster: impact and response in a Houston trauma center intensive care unit.
Nates JL.
Vivian L. Smith Center for Neurologic Research and the Department of Neurosurgery and Anesthesiology/Critical Care, The University of Texas, Houston, TX, USA. jlnates@mdanderson.org
OBJECTIVE: To increase awareness of specific risks to healthcare systems during a natural or civil disaster. We describe the catastrophic disruption of essential services and the point-by-point response to the crisis in a major medical center. DESIGN: Case report, review of the literature, and discussion. SETTING: A 28-bed intensive care unit in a level I trauma center in the largest medical center in the world. CASE: In June 2001, tropical storm Allison caused >3 feet of rainfall and catastrophic flooding in Houston, TX. Memorial Hermann Hospital, one of only two level I trauma centers in the community, lost electrical power, communications systems, running water, and internal transportation. All essential hospital services were rendered nonfunctional. Life-saving equipment such as ventilators, infusion pumps, and monitors became useless. Patients were triaged to other medical facilities based on acuity using ground and air ambulances. No patients died as result of the internal disaster. CONCLUSION: Adequate training, teamwork, communication, coordination with other healthcare professionals, and strong leadership are essential during a crisis. Electricity is vital when delivering care in today's healthcare system, which depends on advanced technology. It is imperative that hospitals take the necessary measures to preserve electrical power at all times. Hospitals should have battery-operated internal and external communication systems readily available in the event of a widespread disaster and communication outage. Critical services such as pharmacy, laboratories, blood bank, and central supply rooms should be located at sites more secure than the ground floors, and these services should be prepared for more extensive performances. Contingency plans to maintain protected water supplies and available emergency kits with batteries, flashlights, two-way radios, and a nonelectronic emergency system for patient identification are also very important. Rapid adaptation to unexpected adverse conditions is critical to the successful implementation of any disaster plan.
Publication Types:
PMID: 15090948 [PubMed - indexed for MEDLINE]
Comment in:
Format of medical order sheet improves security of antibiotics prescription: The experience of an intensive care unit.
Wasserfallen JB, Butschi AJ, Muff P, Biollaz J, Schaller MD, Pannatier A, Revelly JP, Chiolero R.
Medical Direction, Department of Medicine, University Hospital, Lausanne, Switzerland.
OBJECTIVE: To assess whether formatting the medical order sheet has an effect on the accuracy and security of antibiotics prescription. DESIGN: Prospective assessment of antibiotics prescription over time, before and after the intervention, in comparison with a control ward. SETTING: The medical and surgical intensive care unit (ICU) of a university hospital. PATIENTS: All patients hospitalized in the medical or surgical ICU between February 1 and April 30, 1997, and July 1 and August 31, 2000, for whom antibiotics were prescribed. INTERVENTION: Formatting of the medical order sheet in the surgical ICU in 1998. MEASUREMENTS AND MAIN RESULTS: Compliance with the American Society of Hospital Pharmacists' criteria for prescription safety was measured. The proportion of safe orders increased in both units, but the increase was 4.6 times greater in the surgical ICU (66% vs. 74% in the medical ICU and 48% vs. 74% in the surgical ICU). For unsafe orders, the proportion of ambiguous orders decreased by half in the medical ICU (9% vs. 17%) and nearly disappeared in the surgical ICU (1% vs. 30%). The only missing criterion remaining in the surgical ICU was the drug dose unit, which could not be preformatted. The aim of antibiotics prescription (either prophylactic or therapeutic) was indicated only in 51% of the order sheets. CONCLUSIONS: Formatting of the order sheet markedly increased security of antibiotics prescription. These findings must be confirmed in other settings and with different drug classes. Formatting the medical order sheet decreases the potential for prescribing errors before full computerized prescription is available.
Publication Types:
PMID: 15090943 [PubMed - indexed for MEDLINE]
Comment in:
Intensive care decision making in the seriously ill and elderly.
Lloyd CB, Nietert PJ, Silvestri GA.
Division of Pulmonary and Critical Care Medicine at the Medical University of South Carolina, Charleston, SC, USA.
OBJECTIVE: To determine the influence of self-reported preadmission quality of life, hypothetical quality of life and mortality prognosis, and length and intensity of intensive care on decision making in the seriously ill and elderly. DESIGN: Prospective cohort study. SETTING: Medical university. SUBJECTS: Adult inpatients with chronic illness and an estimated 50% 6-month mortality along with patients > or =80 yrs old with an acute illness. INTERVENTIONS: Patients were presented with two scenarios: a) mechanical ventilation for 14 days; and 2) mechanical ventilation for 1 month with tracheostomy and feeding tube placement. A modified time trade-off was used to vary survival and quality of life over plausible ranges. Patients could consent to intensive care or choose care directed at comfort measures. MEASUREMENTS AND MAIN RESULTS: Fifty patients were interviewed. As projected intensive care unit mortality rate or postintensive care unit quality of life decreased, patients were less likely to consent to intensive care. Postintensive care quality of life was as important to patients as intensive care survival estimates. However, prehospitalization quality of life did not significantly influence decision making regarding life-extending treatment. When progressing from the acute intensive care scenario to chronic mechanical ventilation with associated interventions, patients demanded a significant increase in survival and quality of life. Neither race nor previous intensive care unit admission was associated with consent to intensive care. CONCLUSIONS: There is wide variation in preference for aggressive care that does not appear to be influenced by prehospitalization quality of life. However, predicted quality of life appears to be as important as estimates of intensive care unit survival in decision making. When confronted with extended mechanical ventilation and associated care, a significant proportion of patients would accept this care only for an improved prognosis. Length and intensity of intensive care should be incorporated into discussions regarding intensive care.
PMID: 15090942 [PubMed - indexed for MEDLINE]
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Poor correlation between hemodynamic and echocardiographic indexes of left ventricular performance in the operating room and intensive care unit.
Bouchard MJ, Denault A, Couture P, Guertin MC, Babin D, Ouellet P, Carrier M, Tardif JC.
Department of Anesthesiology, Montreal Heart Institute, Montreal, Quebec, Canada.
OBJECTIVES: To compare hemodynamic and echocardiographic indexes of left ventricular performance. DESIGN: Retrospective database analysis of four clinical trials. SETTING: University hospital. PATIENTS: Cardiac surgery patients. INTERVENTION: Left ventricular performance was evaluated using left ventricular stroke work index (LVSWI) calculated from the pulmonary artery catheter and both fractional area change and regional wall motion score index (RWMSI) measured from transesophageal echocardiography. Measures of left ventricular performance were obtained before and after bypass (group 1, n = 30), during acute increase and decrease in preload (group 2, n = 14), after administration of inhaled prostacyclin or placebo in patients with pulmonary hypertension (group 3, n = 20), and in hemodynamically unstable patients in the intensive care unit at admission and at 2 and 4 hrs (group 4, n = 20). MAIN RESULTS: A total of 186 simultaneous LVSWI, fractional area change, and RWMSI were analyzed and compared. Patients with RWMSI <1.3 had a LVSWI of 23.4 +/- 10.3 g.m.m compared with 18.4 +/- 7.2 g.m.m in those with RWMSI >1.3 (p =.0349). Subdividing fractional area change into three different groups (> or =50%, 25% to 49%, and < or =24%), the corresponding values of LVSWI were 22.3 +/- 9.7 g.m.m, 22.2 +/- 10.8 g.m.m, and 17.7 +/- 5.5 g.m.m, respectively (p =.5114). Correlations between LVSWI and RWMSI changes ranged from -0.28 to 0.16 (p values from.31 to.94). Correlations between LVSWI and fractional area change changes ranged from -0.62 to 0.22 (p values from.07 to.95). CONCLUSION: There is a significant discrepancy and limited relationship between the hemodynamic and echocardiographic evaluation of left ventricular performance.
Publication Types:
PMID: 15090941 [PubMed - indexed for MEDLINE]
Comment in:
Use of intensive care at the end of life in the United States: an epidemiologic study.
Angus DC, Barnato AE, Linde-Zwirble WT, Weissfeld LA, Watson RS, Rickert T, Rubenfeld GD; Robert Wood Johnson Foundation ICU End-Of-Life Peer Group.
Department of Health Policy and Management, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA.
OBJECTIVE: Despite concern over the appropriateness and quality of care provided in an intensive care unit (ICU) at the end of life, the number of Americans who receive ICU care at the end of life is unknown. We sought to describe the use of ICU care at the end of life in the United States using hospital discharge data from 1999 for six states and the National Death Index. DESIGN: Retrospective analysis of administrative data to calculate age-specific rates of hospitalization with and without ICU use at the end of life, to generate national estimates of end-of-life hospital and ICU use, and to characterize age-specific case mix of ICU decedents. SETTING: All nonfederal hospitals in the states of Florida, Massachusetts, New Jersey, New York, Virginia, and Washington. PATIENTS: All inpatients in nonfederal hospitals in the six states in 1999. INTERVENTION: None. MEASUREMENTS AND MAIN RESULTS: We found that there were 552,157 deaths in the six states in 1999, of which 38.3% occurred in hospital and 22.4% occurred after ICU admission. Using these data to project nationwide estimates, 540,000 people die after ICU admission each year. The age-specific rate of ICU use at the end of life was highest for infants (43%), ranged from 18% to 26% among older children and adults, and fell to 14% for those >85 yrs. Average length of stay and costs were 12.9 days and $24,541 for terminal ICU hospitalizations and 8.9 days and $8,548 for non-ICU terminal hospitalizations. CONCLUSIONS: One in five Americans die using ICU services. The doubling of persons over the age of 65 yrs by 2030 will require a system-wide expansion in ICU care for dying patients unless the healthcare system pursues rationing, more effective advanced care planning, and augmented capacity to care for dying patients in other settings.
Publication Types:
PMID: 15090940 [PubMed - indexed for MEDLINE]
Comment in:
Low apolipoprotein A-I level at intensive care unit admission and systemic inflammatory response syndrome exacerbation.
Chenaud C, Merlani PG, Roux-Lombard P, Burger D, Harbarth S, Luyasu S, Graf JD, Dayer JM, Ricou B.
Division of Surgical Intensive Care, Department of Anesthesiology, Pharmacology, and Surgical Intensive Care, University of Geneva Hospitals, Geneva, Switzerland.
OBJECTIVE: Examine whether a low serum level of apolipoprotein A-I at intensive care unit (ICU) admission is associated with a further increase of the number of systemic inflammatory response syndrome (SIRS) criteria. DESIGN: Prospective observational study. SETTING: A 20-bed, university-affiliated, surgical ICU. PATIENTS: Patients admitted after major surgery, multiple trauma, or acute pancreatitis without septic shock. INTERVENTIONS: We defined as the SIRS Exacerb group patients who presented a further increase of the number of SIRS criteria during their ICU stay or, in the presence of four SIRS criteria at ICU admission, those who presented a further aggravation of organ failure. Other patients were attributed to the SIRS No Exacerb group. From day 1 to 6, we measured apolipoprotein A-I, high-density lipoprotein and total cholesterol, triglycerides, C-reactive protein, procalcitonin, serum amyloid A, interleukin 6, interleukin-1 receptor antagonist, albumin, and other nutrition-linked variables. We looked at laboratory values or factors present at ICU admission according to the two groups. MEASUREMENTS AND MAIN RESULTS: From 63 patients analyzed, 29 (46%) were assigned to the SIRS Exacerb group. Age, sex, and SAPS II and SIRS scores at ICU admission did not differ between the groups. Patients in the SIRS Exacerb group presented more often a septic event (5/29 vs. 0/34, p =.02), had a higher hospital mortality (6/29 vs. 0/34, p =.007), and had a longer ICU stay (p =.0023). At admission, inflammatory variables such as the C-reactive protein, serum amyloid A, interleukin 6, interleukin-1 receptor antagonist plasma levels, and other lipid or nutrition-linked variables were similar between the two groups. Apolipoprotein A-I levels were lower in the SIRS Exacerb group (median [interquartile range]: 68 [56-81] vs. 84 [69-94] mg/dL, p =.028). CONCLUSION: A low serum level of apolipoprotein A-I at ICU admission is associated with an increase of the number of SIRS criteria during the ICU stay.
PMID: 15090939 [PubMed - indexed for MEDLINE]
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From Resusci-Anne to Sim-Man: the evolution of simulators in medicine.
Grenvik A, Schaefer J.
Safar Center for Resuscitation Research, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
PMID: 15043230 [PubMed - indexed for MEDLINE]
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The incredible career of Peter J. Safar, MD: the Michelangelo of acute medicine.
Grenvik A, Kochanek PM.
Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, USA.
Publication Types:
- Biography
- Historical Article
Personal Name as Subject:
PMID: 15043225 [PubMed - indexed for MEDLINE]
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Systemic lupus erythematosus in the intensive care unit.
Lash AA, Lusk B.
Northern Illinois University, School of Nursing, DeKalb, Ill., USA.
The prototype autoimmune disorder SLE is a highly variable disease characterized by episodic exacerbations, some of which are severe enough to require admission to the ICU. Infection, disease activity, and cardiovascular complications are among the major reasons for admission. Drugs, particularly the immunosuppressants used to treat SLE, often cause as much injury to the immune system as the disease itself, and intensive treatments are often required to combat the side effects of these drugs. Studies indicate that sex, age, and race affect both morbidity and mortality in SLE. Despite well-documented patterns of morbidity and mortality and episodic exacerbations requiring admission to the ICU, the specific nursing care needs of patients with SLE admitted to the ICU have not been investigated.
PMID: 15098311 [PubMed - in process]
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Take a critical look at progressive care.
[No authors listed]
PMID: 15017914 [PubMed - indexed for MEDLINE]
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Neonatal nursing: the first six weeks.
Jones J.
PMID: 15017911 [PubMed - indexed for MEDLINE]
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Association of tension pneumothorax with use of small-bore chest tubes in patients receiving mechanical ventilation.
Behnia MM, Garrett K.
St. Joseph Hospital, Augusta, Ga., USA.
Publication Types:
PMID: 15007895 [PubMed - indexed for MEDLINE]
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Protecting patients during clinical research.
Byers JF.
University of Central Florida, Orlando, Fla., USA.
Publication Types:
PMID: 15007893 [PubMed - indexed for MEDLINE]
Comment in:
One hospital's experience with a CCRN drive. A successful approach.
Shirey MR, Farmer BS, Schnautz LS.
Cardiovascular Services, Deaconess Hospital, Evansville, Ind., USA.
PMID: 15007892 [PubMed - indexed for MEDLINE]
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Postanesthetic care in the critical care unit.
Barone CP, Pablo CS, Barone GW.
College of Nursing, University of Arkansas for Medical Sciences, Little Rock, Ark., USA.
Publication Types:
PMID: 15007891 [PubMed - indexed for MEDLINE]
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Unplanned extubation in adult critical care. Quality improvement and education payoff.
Richmond AL, Jarog DL, Hanson VM.
Surgical Intensive Care Unit, St. Joseph's Hospital, Marshfield, Wis., USA.
PMID: 15007890 [PubMed - indexed for MEDLINE]
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Care of patients after esophagectomy.
Mackenzie DJ, Popplewell PK, Billingsley KG.
Surgical Intensive Care Unit, Veterans Affairs Puget Sound Health Care System, Seattle, Wash., USA.
Publication Types:
PMID: 15007889 [PubMed - indexed for MEDLINE]
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Family visitation.
Stock MA.
Publication Types:
PMID: 15007888 [PubMed - indexed for MEDLINE]
Comment on:
Preceptors helping with remediation.
Jenkins JA.
Publication Types:
PMID: 15007886 [PubMed - indexed for MEDLINE]
Comment on:
Missing opportunities to practice in ICU settings.
Loyd M.
Publication Types:
PMID: 15007885 [PubMed - indexed for MEDLINE]
Comment on:
Placement of a nasogastric tube.
Rajda C.
Publication Types:
PMID: 15007883 [PubMed - indexed for MEDLINE]
Analysis of terminal events in 109 successive deaths in a Belgian intensive care unit.
Gajewska K, Schroeder M, De Marre F, Vincent JL.
Department of Intensive Care, Erasme University Hospital, Route de Lennik 808, 1070, Brussels, Belgium.
OBJECTIVE. To determine the incidence of end-of-life decisions in intensive care unit (ICU) patients. DESIGN AND SETTING. Prospective data collection and questionnaire in a 31-bed medicosurgical ICU in a university hospital. PATIENTS AND PARTICIPANTS. All 109 ICU patients who died during a 3-month period (April-June 2001). Members of the ICU team were also invited to complete a questionnaire regarding the circumstances of each patient's death. Cardiopulmonary resuscitation was performed in 21 of the patients; other mechanisms leading to death were brain death ( n=19), refractory shock ( n=17), and refractory hypoxemia ( n=2). The decision was taken in the remaining 50 patients to withdraw ( n=43) or withhold ( n=7) therapy. Questionnaires were completed for 68 patients, by physician and nurse in 40 cases, physician only in 20 cases, and nurse only in 8 cases. Questionnaires were obtained for 34 of 50 patients for whom a decision was made to limit therapy. RESULTS. Respondents generally felt that the decision was timely ( n=28, 82%), 5 (15%) felt the decision was too late, and one (3%) that the decision was made too soon, before the family could be informed. CONCLUSIONS. Therapeutic limitations are frequent in patients dying in the ICU, with withdrawing more common than withholding life support. Generally members of the ICU staff were satisfied with the end-of-life decisions made.
PMID: 15105984 [PubMed - as supplied by publisher]
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